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Last week we had Andrew Lansley speak at the RSA, setting out his vision for the health service. He didn’t say much about public behaviour and health (although he did say a little), but there’ll be an opportunity to catch up with his views on that at this Social Brain event on June 29th.

Last week we had Andrew Lansley speak at the RSA, setting out his vision for the health service. He didn’t say much about public behaviour and health (although he did say a little), but there’ll be an opportunity to catch up with his views on that at this Social Brain event on June 29th.

 

One thing that came up in his speech was a commitment to choice as a driver of competition, and thus standards of care and efficiency in the NHS. New Labour too is committed to the ‘choice agenda’ in health (although not nearly seriously enough according to Lansley).

 

I wonder about this commitment. There are lots of worries: that only the middle-classes get to exercise choice so that health provision based on it further entrenches inequalities in health outcomes; that we are simply not that good at making choices about our health; that choice-driven competition will lead to hospitals avoiding ‘difficult’ patients and ailments (although it is only fair to say that Lansley did speak to some of these worries). There also seems to be a worry over how the Conservatives (quite admirable) desire to empower and trust the professionalism of doctors and nurses conflicts with the choice agenda – if it is the professional honour and altruism of health workers that secures high standards of care and efficiency, why do we need choice to drive competition, in turn driving up these latter?

 

Setting these worries aside, I have concerns based on some quite simple mathematical considerations (or rather mathematically expressed considerations). As Thomas Schelling noted in his seminal work ‘Macromotives and Microbehavior’, we often do not realise the aggregate effects of individual choices, even when they require no empirical research to be identified. Take, for example, a future in which every family chooses to have two kids, a boy and a girl. Great, one might think, every son will have a sister, and every daughter a brother. But a little reflection will reveal that no daughter will have a sister, and no son a brother. Is that something we want writ large across the whole of society? This result of our collective choices is blindingly obvious, but we need to be reminded of it all the same.

 

Now, take ‘choice’ over which hospital one attends. Say that there are two to choose from within reasonable distance, Butchers’ Den and Slackers’ Yard. Butchers’ Den is very efficient, has short waiting lists and high-standards of care. Slackers’ Yard is overworked, has long waiting lists and care is patchy. People are aware of this information, and start demanding en masse that they be treated at Butchers’ Den. But now, Butchers’ Den’s waiting lists suddenly increase and standards of care drop due to overwork. A lot of the people seen at Butchers’ Den get a bad service, but before this information can be collated and disseminated, a lot more get a really bad service.

 

Eventually the information gets out that Butchers’ Den has gone downhill and Slackers’ Yard has greatly improved. Everybody now chooses to go to the latter. The process repeats and we get an oscillation between everyone wanting to go to each hospital, with the majority of patients getting bad or really bad care. This can all be known without any empirical research into the particular circumstances of either hospital or the population that uses them. It is just a blindingly obvious aggregate-level result of individual choices, given the variables.

 

That this doesn’t happen in reality (where such ‘choice’ exists) is not because the analysis is wrong. Rather, this is what would happen if informed choice were the determinant of which hospital each patient attends. Thus plainly it isn't. So the politicians who advocate the choice agenda in health are in a pickle. Either choice isn’t taken up in reality, or if it is only by a limited few. For if everybody chose their hospital based on the obvious variables, scenarios like the above would emerge – scenarios in which everybody would receive much worse care.

 

Of course these variables might be wrong, but they are the ones the advocates of choice are presupposing.

 

So why does no-one concerned make this blindingly obvious point?

 

 

*** Chris Dillow has pointed out to me that the argument above runs on some specific details, so they should be brought out. Here are two details he suggests are salient:

 

 

1. The fact that Butchers' Den can't cope with the extra patients is that I am presuming it has limited capacity, both in terms of infrastructure and staff. Neither of these can be increased at anything like the rate needed to stop waiting lists lengthening and provision of care suffering from overwork and staff shortages.

 

 

2. Real-time data dissemination is not really possible, it will take months to collate, so that patients cannot get information up to date enough to make decisions that would stop the oscillation effect between hospitals. If real-time info were available, it's collation would take so much time and effort as to make for an even worse bureaucratism than already exists.

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